Vehicle Replacement Form

This form will allow you to send us most of the required information to remove a vehicle on your policy and replace it with an other vehicle. It is mainly for personal use vehicles. If you wish to add a recreational vehicle, motorcycle, snowmobile or other, please contact us.

For your added protection, any change you make to your policy does not become effective until we contact you to verify the change and effective date. This is to protect your existing coverage, should additional information or coverage be required to make the change you have asked.

About you

Name(s) of insured(s)
(as named on your policy)   

1^st Named Insured:

2^nd Named Insured:

Your preferred means of communication for contact and follow-up :
 

E-mail

Phone

We can only accept changes from policyholders.
Please check this authorization box, before completing the rest of the form :
 

 I'm the owner of the policy and I'm authorized to submit these changes.

Disclaimer

E-mail address :

Daytime telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905     Ext.  

Home telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905   

Prior vehicle

Vehicle make :

Year :

Model :

New vehicle

Vehicle make :

Year :

Model :

Condition at time of purchase :  

Select New Demo Used

Purchase date :

 (dd / mm / yyyy)

Purchase price :  

VIN (Vehicle identification number) :  

Check off each safety, security
and communication item
that applies to this vehicle :

Cellular phone
Alarm system
Disabling device
Non-factory installed disabling device
Engraving
Flashing alert light
Tracking system

Have any modifications that are not factory installed been made to the vehicle ?

Yes No

Is there any unrepaired damage ?

Yes No

If Yes, specify :  

Is this vehicle leased or financed?  

Select None Car loan Lease

If Yes, specify :  

The vehicle is registered
under who's name?

Use of vehicle :  

Select Pleasure (no commuting) Commuting to work or school Business Farming Other

If other, specify   :

How many kilometres a year does this vehicle travel?

Select 0 to 5 000 5 001 to 10 000 10 001 to 15 000 15 001 to 20 000 20 001 to 25 000 25 001 to 30 000 30 001 and more

How many kilometres (one way) is this vehicle driven daily to go to work or school ?

Select                  0 less than 9 9 to 16 17 to 24 25 to 34 35 to 50 more than 50

If you have more than one vehicle on your policy, will
the replacement of this vehicle result in changes to
the way the remaining vehicle(s) are used ?

 Yes No
 

Driver Name

Date of birth

Type of driver   

(dd / mm / yyyy)

Select Principal Occasional

(dd / mm / yyyy)

Select Principal Occasional

(dd / mm / yyyy)

Select Principal Occasional

Effective date

When will this change be effective ?

(dd / mm / yyyy)

About your insurance

Specify the policy to which this change applies:

Company

If other, specify

Insurance policy number

Select Intact Insurance ING Novex ING Western Union Other

Do you want to change your coverage ?

Yes No

If Yes, specify :